The relationship between exercise, amenorrhoea, percentage body fat and disordered eating among adolescent female runners

amenorrhoea,

percentage body fat

femaCe runners

arnenorrhoea, percentage body fat and

disordered eating among adoCescent

femafe runners

7"Botha

(KJA. lions.)

Dissertation submitted in partial fuCfiCCment of the

requirements for the degree Magister JArtium in the

faculty of 3-ieaCth Sciences at the Totchefstroom campus

of the :North-^West University.

Supervisor: 'Prof. J:Mde 'Ridcfer

Co-Supervisor: 'Prof V.'DJ MaCan

JAss is ta n t supe rv isor: Vr !H. !H Wrigh t

God, give us the grace to accept with serenity the things that cannot be changed, courage to change the things that should be changed, and the wisdom to

distinguish between them

-- Prayer of St Francis

Without the guidance, grace and mercy of my Heavenly Father, the completion of this study would not have been possible. I am truly grateful for all of the talents and opportunities He has blessed me with and I pray that He will grant me the wisdom and strength to always keep my eyes fixed on Him.

I would also like to express my sincere thanks and appreciation to the following people for their love, patience understanding and unselfish contribution to the completion of this study:

• My parents and my sister, thank you for your support in my studies. Without your belief in my abilities, this dissertation would never have become a reality.

• Willie, thank you for your love, patience, support and faith. You always see the positive side. Thank you for believing in me even in times when I did not. Thank you for being at my side at all times. I love you very much.

• Dr. Gerda Joubert, thank you for your valuable guidance and for sharing your knowledge throughout this study. You have been a role model and someone I look up to.

complete this study. I appreciate everything you have done for me.

d Prof. Dawie Malan, my co-supervisor, thank you for your guidance and integrity.

• Dr. Hattie Wright, thank you for all your assistance and insight regarding the eating disorders and amenorrhoea. Thank you for always being a phone call or e-mail away.

• Dr. Suria Ellis, thank you for attempting to clear up the world of statistics for me. Without you I would have been lost.

• Carolyn Langley, a wonderful friend and co-worker, thank you for all the help and hard work in the technical aspects of this study, and thank you for being there in the good and not so good times.

• Judy Prinsloo, thank you for the constant consultations. Thank you for the motivation you have provided me with throughout this study.

• Mrs. Elsa Brand, your accurate and speedy technical and language editing of this dissertation is sincerely appreciated.

9 Prof. Casper Lessing, thank you for the reference analysis and editing.

• Lastly, to all the athletes and coaches of the North-West Province who participated in this study, thank you for your participation and patience, without you this would never have been possible.

The author May 2008

JAndmy Love

Ml

The co-authors of the articles that form part of this dissertation, Prof. J. Hans de Ridder (supervisor), Prof. Dawie D.J. Malan (co-supervisor) and Dr. Hattie Wright (assistant supervisor), hereby give permission to the candidate, Ms Tershia Botha, to include the two articles as part of a Masters dissertation. The contribution (advisory and supportive) of these co-authors was kept within reasonable limits, thereby enabling the candidate to submit this dissertation for examination purpose. This dissertation, therefore, serves as partial fulfilment of the requirements for the M.A. degree within the School of Biokinetics, Recreation and Sports Science in the Faculty of Health Sciences at the North-West University, Potchefstroom Campus.

Prof. J.H. de Ridder Supervisor and co-author

Prof. D.DJ. Malan

Co-supervisor and co-author

Dr. H.H. Wright

The American College of Sports Medicine first described the Female Athlete Triad a decade ago (ACSM, 1997:5). It is a life-threatening syndrome that is defined by disordered eating, amenorrhoea and osteoporosis (Thompson, 2007:129). Although physical exercise has many benefits, too much exercise can negatively affect the female athlete, causing amenorrhoea. When athletes restrict food intake and train hard, hormonal changes can affect the reproductive system and cause menstrual dysfunction. The first purpose of this study was therefore to determine if there is a relationship between body composition, disordered eating and menstrual dysfunction among a group of 14 - 25 year-old South African female athletes. The second purpose of this study was to determine if there is a relationship between training volume and menstrual dysfunction among a group of 14 - 25 year-old South African female athletes.

Menstrual dysfunction was determined by a self-administered questionnaire and the incidence of disordered eating by the EAT-26 and the EDI questionnaires. Body composition was calculated by using the BOD POD. Menstrual dysfunction and training volume were determined by a self-administered questionnaire and by using the Exercise Dependence Questionnaire. N on-para metric statistics were obtained due to the small sample size and since subjects were recruited on the basis of availability. Descriptive statistics (mean ± SD) of all variables for the total group of female athletes were obtained and the three different groups were compared, using ANOVA and two-way frequency tables. Practically significant differences were determined.

At the time of the survey, 6 athletes had not yet reached menarche, while two of the athletes only reached menarche at the age of 17 years. Practically significant differences were found between the inter-high athletes' age of menarche and the provincial and national athletes' age of menarche. However, no practically significant differences were

BMI and fat-free mass. The inter-high group had a practically significant higher percentage body fat than the provincial group. No practically significant differences were found between the three groups of athletes for all the subscales of the EDI, with the exception of the perfectionism subscaie. The national athletes had a practically significant higher score than both the inter-high and provincial athletes. No practically significant differences were found between the three groups of athletes regarding the EAT-26 as well as the three groups of athletes regarding their training sessions per week, frequency of training sessions per day or the duration of their training sessions. However, 30, 43% reported a change in their menstrual cycle during the training season and 23, 91% reported a change in their menstnjal cycle during the season and with an increase in their training volume.

The total group of athletes was also redivided into groups according to their menstrual dysfunction to evaluate the influence of training volume on amenorrhoea. However, no practically significant differences were found between these three groups of athletes and their training sessions per week, frequency of training sessions per day or the duration of

their training sessions.

It can therefore be concluded that no relationship was found between body composition, disordered eating and menstrual dysfunction or between training volume and menstrual dysfunction among these groups of 14 - 25 year old South African female athletes.

Key words: Female triad, amenorrhoea, eating disorders, adolescents, athletes,

endurance athletes, exercise, BMI, training volume, body composition, osteoporosis, anthropometry, BOD POD, menarche.

Die "American College of Sports Medicine" het 'n dekade gelede vir die eerste keer die Vroulike Atleet-triade (Female Athlete Tnad) beskryf (ACSM, 1997:5). Dit is 'n lewensbedreigende sindroom wat onderskei word deur versteurde eetpattrone, amenorree en osteoporose (Thompson, 2007:129). Hoewel fisieke oefening verskeie voordele inhou, kan te veel oefening die vroulike atleet negatief be'invloed en amenorree veroorsaak. Wanneer altlete voedselirtname beperk en hard oefen, kan hormonale veranderings die reproduksiestelsel aantas en menstruele disfunksie veroorsaak. Die eerste doelwit van hierdie studie was dus om vas te stel of daar 'n verband bestaan tussen liggaamsamestelling, versteurde eetpattrone en menstruele disfunksie binne 'n groep 14 -25-jarige Suid-Afrikaanse vrouelike atlete. Die tweede doelwit van die studie was om vas te stel of daar 'n verwantskap bestaan tussen oefenvolume en menstruele disfunksie binne 'n groep van 14 - 25-jarige Suid-Afrikaanse vroulike atlete.

Menstruele disfunksie is vasgestel deur 'n selfgeadministreerde vraelys en versteurde eetpattrone deur die EAT-26 en die EDI-vraelyste. Liggaamsamestelling is bereken deur die BOD POD te gebruik. Menstruele disfunksie en oefenvolume is vasgestel deur ln

selfgeadministreerde vraelys en deur die Oefeningafhanklikheidsvraelys (Exercise Dependence Questionnaire). Nie-parametriese statistieke is bekom vanwee die kleiD proefgrootte en omdat die proefpersone gekies is op grond van hul beskikbaarheid. Beskrywende statistieke (gemiddeld ± SD) van al die veranderlikes is bekom en die drie groepe is vergelyk deur gebruik te maak van ANOVA- en tweerigttng frekwensietabelle. Prakties beduidende verskille is vasgestel.

Tydens die opname het 6 atlete nog nie menarg bereik nie, terwyl twee van die atlete eers op die ouderdom van 17 jaar menarg bereik het. Prakties betekenisvolle verskille is gevind tussen die interhoeratlete en die provinsiale en nasionale atlete se ouderdom van

tussen die groepe beteffende hoogte, gewig, LMI en vetvry massa nie. Die intern oer groep het 'n prakties betekenisvolle hoer persentasie liggaamsvet gehad as die provinsiale groep. Geen prakties betekenisvolle verskille is gevind tussen die drie groepe atlete vir al die subskale van die ED1 nie, behalwe vir die subskaal oor perfeksionisme. Die nasionale atlete het prakties betekenisvoller hoer tellings behaal as beide die

interhoer- en provinsiale atlete. Geen prakties betekenisvolle verskille is gevind tussen die drie groepe atlete wat betref die EAT-26 sowel as atlete se oefensessies per week, frekwensie van oefening per dag of die duur van hul oefensessies nie. Dertig (30) of 43% het 'n verandering in hul menstruele siklus aangemeld gedurende die oefenseisoen en 23 of 91% het 'n verandering in hul menstruele siklus gedurende die seisoen en met verhoogde oefenvolumes aangemeld.

Die totale groep atlete is weer ingedeel in groepe volgens hul menstruele disfunksie om die oefenvolume se uitwerking op amenorree vas te stel. Geen prakties betekenisvolle verskille is egter gevind tussen die drie groepe atlete en hul oefensessies per week, frekwensie van oefensessies per dag of die duur van hu! oefensessies nie.

Daar kan dus afgelei word dat geen verwantskap gevind is tussen liggaamsamestelling, versteurde eetgewoontes en menstruele disfunksie of tussen oefenvoLume en menstruele disfunksie tussen hierdie groepe van 14 - 25-jarige Suid-Afrikaanse vroulike atlete nie.

Sleutelwoorde: Vroulike atleet-triade, amenorree, eetversteurings, adolessente, atlete,

uithou-atlete, oefening, LMI, oefenvolume, liggaamsamestelling, osteoporose, antropometrie, BOD POD, menarg.

♦ Foreword

♦ Declaration iv

♦ Summary v

♦ Opsomming vii

♦ Table of contents ix

♦ List of figures xiv

♦ List of tables xv

♦ List of abbreviations xvi

CHAPTER 1

THE PROBLEM STATEMENT AND THE AIM OF THE STUDY

1.1 INTRODUCTION 2

1.2 PROBLEM STATEMENT 4

1.3 OBJECTIVES 7

1.4 HYPOTHESES 7

1.5 STRUCTURE OF THE DISSERTATION 8

THE RELATIONSHIP BETWEEN EXERCISE, AMENORRHOEA,

PERCENTAGE BODY FAT, AND DISORDERED EATING IN

FEMALES 14

(Review article)

2.1 INTRODUCTION 15

2.2 ELEMENTS ASSOCIATED WITH THE FEMALE TRIAD 17

2.2.1 Disordered eating 19

2.2.2 Amenorrhoea 20

2.2.3 Osteoporosis 22

2.3 EXERCISE AND THE FEMALE ATHLETE TRIAD 24

2.3.1 Exercise and menstrual cycle disorders 25

2.3.2 Exercise and body composition 27

2.3.3 Exercise and disordered eating 28

2.4 CONCLUSION 30

2.5 REFERENCES 31

CHAPTER 3

BODY COMPOSITION, DISORDERED EATING, AND

MENSTRUAL DYSFUNCTION IN YOUNG FEMALE

ATHLETES 39

(Research article)

SUMMARY 40

3.1 INTRODUCTION 41

3.2 METHODS 44

3.2.1 Subjects 44

3.2.3 Anthropometries measurements 45

3.2.4 Menstrual status 45

3.2.5 Eating patterns and attitudes 46

3.2.6 Statistical analysis 47

3.3 RESULTS 47

3.3.1 Anthropometries measurements 47

3.3.2 Menstrual status 48

3.3.3 Eating patterns and attitudes 49

3.3.3.1 EAT-26 49

3.3.3.2 Eating Disorder Inventory 50

3.4 DISCUSSION AND CONCLUSION 51

3.5 ACKNOWLEDGEMENTS 56

3.6 REFERENCES 57

CHAPTER 4

TRAINING VOLUME AND MENSTRUAL DYSFUNCTION IN

YOUNG FEMALE ATHLETES 66

(Research article)

SUMMARY 67

4.1 INTRODUCTION 68

4.2 METHODS 70

4.2.1 Subjects 70

4.2.2 Menstrual status 70

4.2.3 Training volume 71

4.2.4 Statistical analysis 71

4.3 RESULTS 71

4.3.1 Menstrual status 71

4.4 DISCUSSION AND CONCLUSION 78

4.5 ACKNOWLEDGEMENT 80

4.6 REFERENCES 81

CHAPTER 5

SUMMARY, CONCLUSION AND RECOMMENDATIONS 85

5.1 SUMMARY 86

5.2 CONCLUSIONS 87

5.3 RECOMMENDATIONS 88

5.4 FUTURE RESEARCH 90

APPENDICES 91

Appendices A

♦ Guidelines for Authors 92

o Journal of Human Movement Studies 93

Appendices B

♦ Ingeligte toestemmingsvorm 97

♦ Informed consent 99

Appendices C

♦ Questionnaires 103

> Personal Information 104

> Menstrual History Questionnaire 105

> Training Volume Questionnaire 107

> Exercise Dependence Questionnaire 109

> Eating Disorder Inventory (EDI) Questionnaire 113

Appendices D

CHAPTER 1

Figure 1.1 The female athlete triad 6

Figure 1.2 Structure of dissertation 9

CHAPTER 2

Figure 2.1 The female athlete triad 16

Figure 2.2 The corners of the female athlete triad (osteoporosis,

disordered eating and amenorrhea) are inter-related

through psychological and physiological mechanisms 18

Figure 2.3 Bone mineral densities of amenorrhoeic and normally

menstruating athletes 23

Figure 2.4 Bone density of a competitive female runner against a

69 year-old elderly woman 24

CHAPTER 4

Figure 4.1 Frequency of training sessions per week 73

Figure 4.2 Athletes' training sessions per week 76

Figure 4.3 Athletes' training sessions per day 77

CHAPTER 3

Table 3.1 Anthropometric measurements of female athletes 47

Table 3.2 Chronological and age of menarche of the three groups 48

Table 3.3 Menstrual regularity of the total group and individual

groups of athletes 49

Table 3.4 Descriptive statistics for the Eating Disorder Inventory

(EDI) and the Eating Attitude Test (EAT-26) of the

three groups of athletes 50

CHAPTER 4

Table 4.1 Chronological and age of menarche of the three groups 72

Table 4.2 Menstrual regularity of the total group and individual

groups of athletes 72

Table 4.3 Length of training sessions 74

Table 4.4 Athletes' training sessions per week 75

Table 4.5 Athletes' training sessions per day 75

ACSM

ADP

ANOVA

BD

BMD

BMI

cm

cycles/yr

DE

ED

EAT-26

EDI

EDNOS

e-g-et al.

FFM

ISAK

ml

NCAA

g/cm

American College of Sports Medicine

Air Displacement Plethysmography

Analysis of variance

Body density

Bone mineral density

Body Mass Index

Centimeters

Cycles per year

Disordered eating

Eating disorder

Eating Attitude Test - 26

Eating Disorder Inventory

Eating disorder not otherwise

specified

Example

And others

Fat free mass

International Standards for

Anthropometries Assessments

Milliliter

National Collegiate Athletic

Association

kcal/kg Kilocalory per kilogram

kg Kilogram

kg/m

Kilogram per square meter

kJ/kg Kilojoules per kilogram

km/week Kilometres per week

n Total

SD Standard deviation

WHO World Health Organization

J

The j?r oh fern statement and the aim

of the study

The problem statement and the aim of

the study

1.5 STRUCTURE OF THE DISSERTATION 1.6 REFERENCES

1.1 INTRODUCTION

Irregular menses have been reported to range from 1 % to 66% among athletes, compared with 2% to 5% of the general population (Burrows & Bird, 2000:285; Harmon, 2002:34). The wide range of reported menstrual abnormalities stems not only from different populations surveyed, but also from different criteria used to define the condition (Harmon, 2002:34). Interrelationships among nutrition, exercise intensity and volume, body mass index and psychological stressors contribute to normal menstrual function (Harmon, 2002:30).

The female athlete triad was first officially defined in 1993 by a panel of experts who identified a spectrum of disordered patterns of eating and amenorrhoea in female athletes (Yeager et ah, 1993:776). In the position stand by the American College of Sports Medicine (ACSM) (1997), these ideas were further defined to include three distinct components: (a) disordered eating, (b) amenorrhoea, and (c) osteoporosis (Otis et al, 1997:3; Hobart & Smucker, 2000:3360). Papanek (2003:600) reports that the meeting was called in response to the alarming increase in stress fracture rates, documented decreases in bone mineral density and menstrual dysfunction in otherwise healthy female athletes. Furthermore, the depiction of the triad as a triangle was developed to

demonstrate the interrelationship between the three disorders normally considered to be independent medical conditions (Papanek, 2003:600-602).

The female athlete triad is not a very common condition, but is a very serious one (Peoria, 2001:12). The term refers to a young woman athlete who trains rigorously and has a combination of an eating disorder; amenorrhoea (the absence of menstruation) and osteoporosis, or bone weakness (Hobart & Smucker, 2000:3357; Peoria, 2001:10; Barr & Rideout, 2004:696, Birch, 2005:244). Typically, young athletes with these conditions -or those who are at risk f-or these conditions - may severely restrict what they eat -or binge and purge in order to lose weight or remain thin (Otis et al, 1997:2; Peoria, 2001:14). In addition to having an eating disorder, these young athletes may exercise much more intensely or longer than is required for normal training (Peoria, 2001:15).

Epidemiological studies have shown rates of triad as high as 62% in female athletes (De Souza, 2003:1558; Warren, 2007:1393). Athletes most at risk are those participating in sports such as figure skating and dancing where appearance is judged, or sports in which low body weight is the norm, such as distance running and gymnastics (De Souza, 2003:1558; Warren ef al, 2003:401).

Amenorrhoea can occur in the context of eating disorders or exercise (Rome, 2003:360). DiPietro and Stachenfeld (1997:2) support this by adding that a chronic negative energy balance, being underweight and exercise stress are important elements in the pathway to amenorrhoea. Cobb (2003:715) write that female athletes with disordered eating may limit their calorie and/or fat intakes but maintain high training levels, often resulting in a state of chronic energy deficit. Athletic amenorrhoea occurs more frequently in activities such as long distance running, ballet and gymnastics, in which intense physical training is combined with the desire to maintain a lean build (Beals & Manore, 2002:285; Harmon, 2002:34; De Souza, 2003:1558).

Continuing the triad syndrome's assault on the female athlete's wellness is the relationship between the absence of menses and bone deterioration. There is a prevailing myth in women's athletics that equates a disrupted menstrual cycle with the appropriate level of elite training (Papanek, 2003:611), while others regard it as a great solution to a monthly inconvenience (National Institute of Health, 2003).

1.2 PROBLEM STATEMENT

Body composition is important for optimal physical performance in many sports (Heyward & Wagner, 2004:708). In long distance running specifically, a lean body is regarded as a prerequisite for optimum performance (Greydanus & Patel, 2002:571). According to Greydanus and Patel (2002:558), the pressure to obtain the "ideal" body along with the intense exercise requirement of athletes could lead to the female triad. The female triad can be defined as a syndrome consisting of three components: disordered eating, amenorrhoea and osteoporosis (Otis et al., 1997:9; Barr & Rideout, 2004:694).

The popularity of competitive sports and the number of women that are taking part in sports and especially in top-level competition have increased substantially in recent times (Donaldson, 2003:322). Exercise has many benefits, namely mental and physical advantages (Warren, 1999:1893; Sambanis et al., 2003:401). However, excessive training may lead to health problems in the long term, including menstrual dysfunction, especially in women who practice athletics, rhythmic gymnastics and dance (Warren, 1999:1894; Sambanis et al., 2003:400). Irregular menses have been reported to range from 1% to 66% among athletes, compared with 2% to 5% of the general population (Burrows & Bird, 2000:285; Harmon, 2002:53). Primary amenorrhoea is defined as the absence of menstruation by age 16 in a girl with well-developed secondary sex characteristics; secondary amenorrhoea is the absence of three or more consecutive menstrual cycles after menarche; and oligomenorrhoea is defined as less or equal to six menses per year (Harmon, 2002:50; Warren et al, 2002:513; Sherman & Thompson, 2004:199).

Amenorrhoea is a relatively common disorder with a prevalence that has been difficult to determine because of the variability in definition (West, 1998:66). Amenorrhoea has been reported to be between 3,4% to 66% in some segments of the athletic population (West, 1998:66).

The intensity of exercise and low energy consumption, specific type and amount of training, early age of reaching top level of performance, previous menstrual dysfunctions, low body mass index (BMI) or percentage body fat, pathological eating habits and psychological stress have been suggested as potential factors accountable for menstrual irregularities in female athletes (Malina, 1999:295; Beunen et ai, 1999:285; Manore, 2002).

Strenuous physical activity may affect the female reproductive system, which can lead to athletic amenorrhoea (Warren, 1999:1894; Cobb, 2003:711). The term athletic amenorrhoea refers to amenorrhoea that cannot be explained by any known aetiology other than the exercise training, and therefore its determination is made by exclusion. The prevalence of amenorrhoea among athletes is 4-20 times higher than among the general population (De Cree, 1998:372; De Souza, 2003:1558; Warren, 2007:1393), and appears to be higher (67% vs. 9%) in younger athletes who train intensively, and in certain types of sports in which leanness may provide a competitive advantage (Redman & Loucks, 2005:747). One of the major concerns of athletic amenorrhoea is the low oestrogen levels, which despite the relative protection by the weight-bearing activity, may result in reduced bone mass, due to inadequate acquisition of peak bone mass during the critical period of puberty, and/or due to excessive bone loss in later years. The resulting osteopenia may expose the young female athlete to an increased risk of skeletal fragility, fractures and vertebral instability and curvature (Hobart & Smucker, 2000:3357).

All female athletes are at risk for developing the triad; but the actual magnitude of the problem is unknown (Sanborn et ai, 2000:212). The actual prevalence of the female athlete triad is unknown (Hobart & Smucker, 2000:3364), because of the secretive nature

of the disordered eating component and underreporting by female athletes (Sanborn et ai, 2000:211).

In this study, the aim is to provide a practical way of assessing the first signs of the female athlete triad in order to easier identify and refer athletes at risk. This will be done by assessing eating behaviours, the prevalence of amenorrhoea, exercise history and body composition.

The questions to be answered in this study are firstly if menstrual dysfunction has any association with body composition and disordered eating in 1 4 - 2 5 year-old female athletes and secondly if menstrual dysfunction has any association with training volume in 14 - 25 year-old female athletes. These questions could possibly help to describe the role that body composition, eating disorders and training volume plays in the prevalence of amenorrhoea.

Disordered eating

Menstrual dysfunction Osteoporosis

1.3 OBJECTIVES

The aims of the study are to determine if there is:

• A relationship between body compositions, and menstrual dysfunction among 1 4 - 2 5 year-old female athletes;

• A relationship between disordered eating and menstrual dysfunction among 1 4 - 2 5 year-old female athletes; and

• A relationship between training volume and menstrual dysfunction among 1 4 - 2 5 year-old female athletes.

1.4 HYPOTHESES

This study is based on the following hypotheses:

• There is a positive relationship between body composition and menstrual dysfunction in 14 - 25 year-old female athletes.

• There is a positive relationship between disordered eating and menstrual dysfunction in 14 - 25 year-old female athletes.

• The training volume of the female athlete plays a significant role in the prevalence of menstrual dysfunction.

1.5 STRUCTURE OF THE DISSERTATION

When the literature was studied it became clear that more information was needed on the prevalence of amenorrhoea in 14 - 19 year-old middle and long distance female athletes.

This dissertation is presented in four main parts, namely an introduction (Chapter 1), a review article (Chapter 2) and two research articles (Chapter 3 & 4). A summary with a discussion, a conclusion and recommendations will follow in Chapter 5. The introduction presents the problem statement, objectives and hypotheses. The articles were each written according to the instructions to authors of the journal to which the article will be submitted. The review article (Chapter 2) is based the components of female triad and physical activity. The research article (Chapter 3), investigates the association between body composition, disordered eating and menstrual dysfunction, while Chapter 4 investigates the relationship between training volume and menstrual dysfunction in female athletes. The results of the studies in Chapter 3 and 4 are presented and interpreted in each chapter respectively and then summarised in Chapter 5, together with conclusions and recommendations. Chapter 5 is followed by a list of appendices.

CHAPTER 1

Background, problem statement,

CHAPTER 2

Amenorrhoea - the female triad

CHAPTER 3

Body composition, disordered eating and menstrual dysfunction in young female

athletes

CHAPTER 4

Training volume and menstrual dysfunction in young female

athletes

\

CHAPTER 5

Summary, conclusions and recommendations

V J

APPENDICES

1.6 REFERENCES

AMERICAN COLLEGE OF SPORTS MEDICINE. 1997. ACSM position stands on the female athlete triad. Medicine and science in sports and exercise, 29:i-ix.

BARR, S.I. & RIDEOUT, C.A. 2004. Nutritional considerations for vegetarian athletes.

Nutrition, 29(7-8):696-703.

BEALS, K.A. & MANORE, M.M. 2002. Disorders of the female athlete triad among collegiate athletes. International journal of sport nutrients and exercise metabolism,

12:281-293.

BEUNEN, G.P., MALINA, R.M. & THOMIS, M. 1999. Physical growth and maturation of female gymnasts: human growth in context. London: Smith-Gordon.

BIRCH, K. 2005. Female athlete triad. Sports and exercise medicine, 330:244-246.

BURROWS, M. & BIRD, S. 2000. The physiology of the highly trained female endurance runner. Sports medicine, 30(4):281-300, Oct.

COBB, K.L. 2003. Disordered eating, menstrual irregularity and bone mineral density in female runners. Medicine and science in sports and exercise, 35(5):711-719.

DE CREE, C. 1998. Sex steroid metabolism and menstrual irregularities in the exercising female. Sports medicine, 25(6):369-406.

DE SOUZA, M.J. 2003. Menstrual disturbance in athletes: a focus on luteal phase defects. Medicine and science in sports and exercise, 35:1553-1563.

DIPIETRO, L. & STACHENFELD, N.S. 1997. The female athletic triad: American College of Sports Medicine position. Medicine and science in sports and exercise, 29:1-9.

DONALDSON, MX. 2003. The female athlete triad: a growing health concern.

Orthopedic nursing, 22(5):322-324, Sept-Oct.

DRINKWATER, B.L., LOUCKS, A., SHERMAN, T., SUNDGOT-BORGEN, J. & THOMPSON, R.A. 2000. Position stand on the female athlete triad. IOC Medical Commission Working Group Women in Sport, p. 1-27.

GREYDANUS, D.E. & PATEL, D.R. 2002. The female athlete: before and beyond puberty. Pediatric clinics of North America, 49(3):553-580, Jun.

HARMON, K.G. 2002. Evaluating and treating exercise-related menstrual irregularities.

Physician and sports medicine, 30(3):29-30; 33-35, Mar.

HEYWARD, D.R. & WAGNER, V.H. 2004. Applied body composition assessment. 2nd ed. Champaign, 111.: Human Kinetics. 710 p.

HOBART, J. & SMUCKER, D. 2000. The female triad. American family physician, 61(11):3357-3364, Jun.

MALINA, R.M. 1999. Growth and maturation of elite female gymnasts: is training a factor? Human growth in context. London: Smith-Gordon.

MANORE, M.M. 2002. Dietary recommendations and athletic menstrual dysfunction.

Sports medicine, 32(14):887-901.

NATIONAL INSTITUTE OF HEALTH. 2003. Fitness and bone health: the skeletal risk of over training. Bethesda, Md: National Resource Center.

OTIS, C.L., DRINKWATER, B., JOHNSON, M., LOUCKS, A. & WILLMORE, A. 1997. American College of Sports Medicine position stand: the female athlete triad.

PAPANEK, P.E. 2003. The female athlete triad: an emerging role for physical therapy.

Journal of orthopedic & sports physical therapy, 33(10):594-614.

PEORIA, A.H. 2001. Eating disorders and the female athlete. Athletic therapy today, 2:10-15.

REDMAN, L.M. & LOUCKS, A.B. 2005. Menstrual disorder in athletes. Sports

medicine, 35(9):747-755.

ROME, E.S. 2003. Eating disorders. Obstetrical and gynecological survey, 30(2):353-377.

SAMBANIS, M., KOFOTOLIS, N., KALOGEROPOULOU, E., NOUSSIOS, G., SAMBANIS, P. & KALOGEROPOULOS, J. 2003. A study of the effects on the ovarian cycle of athletic training in different sports. Journal of sports medicine and

physical fitness, 43:398-403.

SANBORN, C.F., HOREA, M., SIEMERS, B.J. & DIERINGER, K.I. 2000. Disordered eating and the female athlete triad. Clinics in sports medicine, 19(2): 199-213.

SHERMAN, R.S. & THOMPSON, R.A. 2004. The female athlete triad. Journal of

school nursing, 20(4): 197-202.

WARREN, M. 1999. Health issue for women athletes: exercise induced amenorrhea.

Journal of clinical endocrinology and metabolism, 84(6): 1892-1896.

WARREN, M.P. 2007. Amenorrhea in endurance runners. Journal of clinical

endocrinology and metabolism, 75(6):1393-1397.

WARREN, M.P., BROOKS-GUNN, J. & FOX, R.P. 2003. Persistence osteopenia in ballet dancers with amenorrhea and delayed menarche despite hormone therapy: a longitudinal study. Fertility and sterility, 80(2):398-404.

WARREN, M.P., RAMOS, R.H. & BRONSON, E.M. 2002. Exercise associated amenorrhea. Physician and sports medicine, 30(10):513-520, Oct.

WEST, V.R. 1998. The triad of disordered eating: amenorrhea and osteoporosis. Sports

medicine, 26(2):63-71, Aug.

YEAGER, K.K., AGOSTINI, R., NATIV, A. & DRINKWATER, B. 1993. The female athlete triad: disordered eating, amenorrhea, osteoporosis. Medicine and science

Chapter 2

The reCationship Between exercise,

amenorrhoea, percentage Body fat

and disordered eating infemaCes

Disordered Eating

A

The relationship between exercise,

amenorrhoea, percentage body fat

and disordered eating in females

2.1 INTRODUCTION

2.2 ELEMENTS ASSOCIATED WITH THE FEMALE TRIAD 2.2.1 Disordered eating

2.2.2 Amenorrhoea 2.2.3 Osteoporosis

2.3 EXERCISE AND THE FEMALE ATHLETE TRIAD 2.3.1 Exercise and menstrual cycle disorders

2.3.2 Exercise and body composition 2.3.3 Exercise and disordered eating 2.4 CONCLUSION

2.5 REFERENCES

2.1 INTRODUCTION

The opportunities for adolescent girls and young adult women to participate at all levels of sports competition have increased substantially since the institution of Title IX in 1972 (Natriv et al, 1994:405; Vinci, 1999:16-17; Hobart & Smucker, 2000:3357; Hinton & Kubas, 2005:149). Twenty-five years ago, only 16 000 women participated in intercollegiate athletics. By 2001, more than 157 000 women competed in National Collegiate Athletics Association (NCAA)-member teams and according to Hinton and Kubas (2005:149), the numbers are still growing. This trend can be regarded as a positive sign for women's health because with increased physical activity comes associated wellness benefits. Willmore and Costill (1999:60) indicate that chronic physiological adaptation to exercise training has been well-documented with regard to

improved cardiovascular efficiency, muscular strength, self-esteem and overall body image.

Ramos and Lola (2004:63) claim that there are many non-competitive women who also exercise vigorously. This mindset results in training becoming a lifestyle philosophy as well as a passion. While this is generally an admirable trait, it is not without significant risk. For example, over-training injuries in the form of muscular strain, tendonitis and stress fractures will likely occur in many individuals, as well as competitively trained athletes who overexert themselves at the expense of sufficient recovery and nutrition (De Oliveira et ai, 2003:357; Ramos & Lola, 2004:58). There is ample evidence that for young women, there are a greater health concern that far outweighs the typical "overuse syndrome", called the female athlete triad (Otis et ai, 1997:3; Robert & Rebar, 2003:7-9; Ramos & Lola, 2004:61). Fig 2.1 illustrates the full rage of the Triad.

Optima! Erie?gy Availability

Reduced Btorgy ftvaifaoility with 3r without Oisoneered Eating Low Energy Availability

with or without an Eating Disorder Functional Hypothalamtc Amenarrhea Eumenorrhea Subdinicai M«nttru3( Disorders 2 p Optimal Sons ^ Health Osteoporosis

Figure 2.1: The female athlete triad. The spectrum of energy availability, menstrual function, and bone mineral density along which female athletes are distributed (narrow arrows). An athlete's condition moves along each spectrum at a different rate, in one direction or the other, according to her diet and exercise habits. Energy availability, defined as dietary energy intake minus exercise energy expenditure, affects bone mineral density both directly via metabolic hormones and indirectly via effects on menstrual function and thereby estrogen (thick arrows) (Nattiv et ai, 2007).

The female athlete triad refers to three interrelated conditions, namely disordered eating, amenorrhoea and osteoporosis (Hobart & Smucker, 2000:3357; Cobb el ai, 2003:711; Barr & Rideout, 2004:696; Birch, 2005:244). While on its own each portion of the triad increases the chance of morbidity and mortality, the danger of the three together increases this chance (Otis et al., 1997:iii; West, 1998:66; Beals et al., 1999:338; Hobart & Smucker, 2000:3357). In endurance sports, a low body fat (11 - 22%) is desirable because it is believed to enhance performance (Wolf et ai, 1997:295; Stokjc et al.. 2005:195) and therefore all female athletes that are participating in such events are at risk for developing the triad (Sanborn et ai, 2000:200; Greydanus & Patel, 2002:553). According to Hobart and Smucker (2000:3360), the actual magnitude of the triad is unknown, mostly because of the secretive nature of the disordered eating component and underreporting by female athletes in this regard (Sanborn et ai, 2000:201; Hebert & McClean, 2003:573). It is therefore necessary to discuss the influence of exercise and/or physical activity on the various components of the triad.

2.2 ELEMENTS ASSOCIATED WITH THE FEMALE TRIAD

The female athlete triad has long been recognised as a syndrome that has the potential to affect female athletes. It consists of three inter-related elements: disordered eating, amenorrhoea, and osteoporosis. The potential impact of each and the combination of these disorders are regarded as detrimental to women's performance and their health (Birch, 2005:244).

Psychological''competitive stress { training volume +■ \ energy intake Aiteratiom in the hypothaiarnic-piluitary control of the menstrual cycle {Risk.of becoming amenorrhoeic Potential of 4 bone

mineral density } Ovarian production _{of oestrogen}

Figure 2.2: The corners of the female athlete triad (osteoporosis, disordered eating and amenorrhoea) are inter-related through psychological and physiological mechanisms (Birch, 2005).

The three corners of the triad are inter-related through psychological and physiological mechanisms, as illustrated in Figure 2.2. The psychological pressures to perform to an optimal level during exercise or competition, and thus often a personally perceived requirement to maintain a low body mass, result in a high volume of training (Birch, 2005:244). The high volume of training and low energy intake, in addition to stress hormones produced by psychological stress, may lead to a physiological alteration in the endocrinological control of the menstrual cycle, which may ultimately lead to the athlete becoming amenorrhoeic (Birch, 2005:244). The consequence of being amenorrhoeic through dysfunction of the hypothalamus and pituitary gland is a decreased production of oestrogen. This hormone plays a major role in maintaining adequate bone mineral density, as a hypo-oestrogenic state (low oestrogen) is associated with low bone mineral density and an increased risk of osteoporosis (Birch, 2005:244).

The different components of the female triad will now be discussed.

2.2.1 Disordered eating

The term "disordered eating" is preferred to "eating disorder", as it implies a spectrum of abnormal behaviour that at its extreme includes anorexia nervosa and bulimia nervosa (Beals et al, 1999:339; Hobart & Smucker, 2000:3358; Klopp et al, 2003:745). Disordered eating occurs in 5% of the general population (Donaldson, 2003:330), but affects as many as two thirds of young female athletes (Joy et al, 1997:98; Putukian, 1998:678; Anderson et al, 2000:612; Hobart & Smucker, 2000:3361; Sundgot-Borgen & Torstveit, 2004:25), because they are potentially driven by a need to maintain a low body weight for performance.

Disordered eating, which includes skipping meals, eating less, vomiting, the use of laxatives and diuretics, describes a broad range of behaviours used to maintain or lose weight (Sanborn et al, 2000:211; Papanek, 2003:601; Birch, 2005:245; Nichols et al, 2006:690; Ronco, 2007:22). Another common disordered eating behaviour is to restrict the intake of certain foods, particularly those high in fat and/or protein (Otis et al,

1997:2; Sanborn et al, 2000:199; De Oliveira et al, 2003:358). Other disordered eating behaviours include binge eating and/or purging. Purging includes not only self-induced vomiting but also the use of diet pills, laxatives, and diuretics, as well as an increase in exercise (Sanborn et al, 2000:199; Donaldson, 2003:323; Ronco, 2007:22).

Although it has been reported that disordered eating involving acute body weight fluctuation (4,5 kg loss and regain) has been associated with amenorrhoea (Cobb et al, 2003:711), it has been confirmed by Loucks et al. (1998:38) that there is no specific percentage body fat below which regular menstruation ceases. Some athletes with amenorrhoea regain their menstrual cycle after intervals of rest, even without an increase in bodyweight or body fat, suggesting that amenorrhoea is not caused solely by low bodyweight or body fat (Loucks et al, 1998:38; Drinkwater et al, 2000:18). In an investigation, De Souza and Williams (2004) suggest that reduced energy availability can be regarded as the main cause of the central suppression of the hypothalamic

pituitary-gonadal axis. They define energy availability as dietary energy intake minus energy expenditure and demonstrate that the relationship between energy expenditure and caloric intake and not each component separately, is the major factor that alters both metabolic and reproductive hormone secretion in elite athletes. Furthermore, it was also found that there is an energy availability threshold of 20-25 kcal/kg lean body mass, and that menstrual disturbances occur only in female athletes who have energy availability below this threshold (Manore, 1999:551; Elford & Spence, 2002:85, Redman & Loucks, 2005:751).

Disordered eating associated with training and sport performance has been distinguished from pathological anorexia by the use of the term 'anorexia athletica' (Birch, 2005:245). The criteria for 'anorexia athletica' in athletes include perfectionism, compulsiveness, competitiveness, high self-motivation, menstrual disturbances and at least one unhealthy method of weight control (Birch, 2005:245). Athletes in this 'anorexia athletica' category will show signs of disordered eating, as opposed to an eating disorder, and clinical observations indicate a prevalence of 15 - 60% for disordered eating, with 50% of these women compulsively over-exercising (Birch, 2005:245).

For female athletes who participate in aesthetical-acrobatic activities and strenuous endurance sports, low body fat is desirable because it is believed to enhance performance (Stokic et al, 2005:195). Manore (2002:890) reports that for many female athletes, constant energy restriction has become a normal part of their lifestyle and is one of the primary factors contributing to menstrual dysfunction in this population.

2.2.2 Amenorrhoea

Amenorrhoea is defined as the 'absence of menstrual bleeding' and can be classified as either primary or secondary (West, 1998:65; Beals et al, 1999:339; American Academy of Pediatrics, 2000:610; Hobart & Smucker, 2000:3357). The Practice Committee of the American Society of Reproductive Medicine (2004) has recently defined primary amenorrhoea as the absence of menstrual cycles in a girl who has not menstruated by 16 years of age, even though she has undergone other normal changes that occur during

puberty. Secondary amenorrhoea refers to the absence of three or more consecutive menstrual cycles after menarche (Hobart & Smucker 2000:3357; Otis & Goldingay, 2000; Warren & Goodman, 2003:875; Practice Committee of the American Society for Reproductive Medicine, 2004:268). In an attempt to standardise future reports, the International Olympic Committee has defined amenorrhoea as 1 menstrual period or less per year. Amenorrhoea is a relatively common disorder among female athletes with a prevalence that has been difficult to determine because of the variability in definition (West, 1998:65).

Amenorrhoea has been reported to occur between 3,4% to 66% in the athletic population (West, 1998:66). A number of factors, such as energy balance, disordered eating behaviours, exercise intensity and training practices, body weight and composition, and physical and emotional stress may contribute to the development of athletic menstrual dysfunction, resulting in amenorrhoea (Manore, 2002). These factors may cause hypothalamic dysfunction and suppression of the spontaneous pulsatile secretion of the gonadotropin-releasing hormone (Redman & Loucks, 2005:749). Several mechanisms have been suggested to explain this suppression. It has been suggested that the later age of menarche in female athletes is due to genetic factors, since non-athletic mothers and sisters of female amenorrhoeic athletes also have a higher prevalence of menstrual abnormalities (Malina et al, 1994:417; Redman & Loucks, 2005:750). Genetic factors, however, cannot explain such a higher prevalence (up to 20 times) of menstrual dysfunctions above the general population (Malina et al., 1994:417; Redman & Loucks, 2005:750).

Numerous studies have associated the prevalence of menstrual cycle irregularity with the age of the athletes, low body fat percentage, bodyweight changes, training intensity, age at menarche, intense training before menarche, prior menstrual cycle irregularities, prior training histories, the endocrine conditioning model, the energy drain theory, pregnancy and endogenous opioids (Bale, 1994:348; Burrows & Bird, 2000:21). However, research indicates that menstrual disturbances may not be caused by bodyweight loss or low body fat levels alone, but can be combined with a host of other factors already mentioned.

Indeed, Keizer and Rogol (1990:219) and Prior et al. (1990:125) state that no one factor can be the singled out as the primary cause of menstrual cycle dysfunction and that athletic amenorrhoea results from a manifestation of nutritional deprivation, physical illness, stress and excessive exercise (Burrows & Bird, 2000:21).

The athletic female who experiences a disruption in her menstrual cycle is at great risk for developing osteoporosis (Hobart & Sumcker, 2000:3357).

2.2.3 Osteoporosis

Osteoporosis, the third component of the female triad, refers to inadequate bone formation and premature bone loss, resulting in low bone mass and increased risk of fracture (Beals et al, 1999:339; Sanborn et al, 2000:202 Hobart & Smucker 2000:3357). In the case of the active athlete, premature osteoporosis puts the athlete at risk for stress fractures as well as more devastating fractures of the hip or vertebral column (Hobart & Smucker, 2000:3357). Osteoporosis affects 25 million individuals in the United States of America alone and causes 1, 5 million fractures each year (West, 1998:66). Osteoporosis can occur if the bone mineral density (BMD) is less than 2,5 standard deviations below the mean value for a specific age group (O'Brien, 2001:59; Khan et al, 2002:11; Waldrop, 2005:215; Birch, 2005:245). Birch (2005:244) claims that women with low energy availability and low oestrogen concentrations have increased risk of becoming osteoporotic.

The risk for developing osteoporosis is greater in female athletes if there is a disruption in their menstrual cycles (Sanborn et al, 2000:202). This may be partially irreversible, despite resumption of menstruation, oestrogen replacement or calcium supplementation (Warren et al, 2002:515; Cobb et al, 2003:711; De Souza & Williams, 2004:19).

It has been found that both athletic and non-athletic women with amenorrhoea have lower vertebral BMD compared with healthy women (Rencken et al, 1996:239; Ronco, 2007:22). De Souza and Williams (2004:10) report that the vertebral BMD was significantly lower in athletes with a history of irregular menses and that a linear

relationship existed between irregularity and vertebral BMD. De Souza and Williams (2004:10) also report that vertebral BMD in athletes with amenorrhoea was 20% lower than that of healthy athletes and 10% lower than that of non-athletes of a similar age with a normal menstrual cycle, as shown in Figure 2.3.

Figure 2.3: Bone mineral density of amenorrhoeic (blue/dark bars) and normally menstruating athletes (orange/light bars). From: De Souza & Williams (2004:10).

According to Snow-Harter (1994:400), some women with exercise-induced amenorrhoea have a bone density typical of that found in an elderly woman, as illustrated in Figure 2.4.

B

n

Figure 2.4: Bone density of a competitive female runner (right) against a 69 year-old woman (left). (Snow-Harter, 1994:400).

The cross in the right panel illustrates the bone density of a 28 year-old competitive female runner. The subject had normal menstrual cycles at the time of the bone scan, but had an 8 year history of exercise-induced amenorrhoea. Her spine bone density (0.874 g/cm2) is nearly equivalent to that of 69 year-old woman (0.877 g/cm2) depicted by the

cross in the left panel. The older woman's spine density, according to Snow-Harter (1994:400), is average for her age, but the runner's spine density is well below the average value for her age (Snow-Harter, 1994:400).

2.3 EXERCISE AND THE FEMALE ATHLETE TRIAD

There appears to be an increasing number of children who specialise in a sport at an early age, train year-round for a sport, and compete at an elite level (Committee on Sports Medicine and Fitness, 2000:154). To be competitive at a high level requires training regimens for children that could be considered extreme, even for adults. The ever-increasing requirements for performance creates a constant pressure for athletes to train longer, harder, more intelligently and in some cases at an earlier age (Committee on Sports Medicine and Fitness, 2000:154). The necessary commitment and intensity of

training raised concerns about the sensibility and safety of high-level athletics for any young person (Committee of Sports Medicine and Fitness, 2000:154).

Regular exercise may result in physiological and psychological benefits and is recommended in both the prevention and treatment of physical disorders/conditions such as coronary heart disease, hypertension and obesity as well as psychological problems such as depression and anxiety (Otis & Goldingay, 2000; Vardar et ah, 2005:550; Ronco, 2007:22). However, the literature suggests that exercise may also have harmful effects on the individual, particularly in terms of exacerbating physical injuries (Zeni-Hoch et

al, 2003:379; De Souza & Williams, 2004:01). Most individuals who participate in sport

and exercise have a positive experience, providing and improving physical fitness and better health (De Souza & Williams, 2004:01). Yet, for some women, the desire for athletic success, combined with the pressure to achieve a desired body weight, may lead to the development of medical disorders, namely eating disorders, amenorrhoea and osteoporosis, collectively known as the female athlete triad (ACSM, 1997:5; Cobb et al, 2003:711). The interaction between exercise and these factors associated with the female athlete triad will be discussed briefly.

2.3.1 Exercise and menstrual cycle disorders

Whilst there is no published research supporting the myth that vigorous exercise during menstruation can have a direct, long term detrimental effect on the female reproductive system, research has suggested an association between vigorous training and a variety of menstrual cycle disorders that are prevalent in athletic women (Warren, 2007:1393). Although the true incidence of menstrual cycle alterations associated with chronic exercise are not fully understood or known, the causes are mainly thought to be multifactoral, including rapid loss in bodyweight (Warren, 2007:1393), sudden onset of strenuous training (Redman & Loucks, 2005:748; Birch, 2005:244), inadequate nutrition to meet energy requirements (Manore, 2002:888; Birch, 2005:244), and psychological and/or physical stress (Warren & Perlroth, 2001:5; Birch, 2005:244).

It has been reported that amenorrhoea occurs in 3,4% to 66% in the athletic population (Vinci, 1999:17; Hobart & Smucker, 2000:3361; Warren, 2007:1393), compared with 2 -5% of women in the general population (Vinci, 1999:16-17). The pathophysiology of exercise-associated amenorrhoea is complex, with varied contributions by weight loss, lowered body fat, emotional stress and physical stress (West, 1998:66; Vinci, 1999:16-17). It has been reported that athletes who begin training at an early age (prior to the age that normal menarche starts - 12 to 16 years of age), have a higher incidence of amenorrhoea than those who begin training after menarche (Loucks, 2003:144; Redman & Loucks 2005:747). Loucks (2003:144) also found that athletes with amenorrhoea also train at high intensities. There is also a higher level of stress with training in athletes with amenorrhoea than in healthy athletes (Drinkwater et ah, 2000:2).

Strenuous exercise may affect the female reproductive system and can lead to athletic amenorrhoea (Redman & Loucks, 2005:747; Birch, 2005:244). The prevalence of menstrual dysfunction in runners ranges from 6% - 43%, depending on the definition of the menstrual problem (Warren & Perlroth, 2001:5; Manore, 2002:888). In a study of female athletes, the incidence of menstrual dysfunction was 7% and appears to be more frequent in athletes who weighed less and were slightly younger (Warren, 2007:1393).

Warren (2007:1393) has shown that amenorrhoea is directly related to weekly training mileage and it could therefore be assumed that long distance female athletes would have the highest incidence of this problem. Studies on English runners spanning similar broad ranges of gynaecological age indicated that the incidence of amenorrhoea rose from 2% to 31% (Rosetta et ah, 1998:348; Burrows et ah, 2003:68) as training mileage increased from 48 to 68 km/week. Among Unites States collegiate runners, the incidence of amenorrhoea ranged from <16 to >113 km/week, while body weight decreased from >60 to <50kg (Sanborn et ah, 1982:859-860). In young competitive long distance female athletes who train 18 hours/week, the incidence of amenorrhoea was 65% (Dusek, 2001:79-80). The concern for the female endurance runner is the alterations in menstrual cycle regularity often reported in those with high training volumes and/or intensities (>20 to 30 km/week and the concomitant effects on health (Burrows & Bird, 2000:33),

probably because both are related to dietary restricting and low body weight. This shows that if athletes train harder, there is a higher incidence of amenorrhoea.

Clark (2002:7) reveals that although amenorrhoea is not sport-specific, sports with the highest prevalence of amenorrhoea include ballet (19 - 44%) and competitive running (24 - 26%), probably because the sport requires a lean body weight. Clark also indicates that a female athlete is more likely to become amenorrhoeic if she has a restrictive diet, low body weight or body fat percentage, has lost weight quickly, exercises vigorously or had an irregular menstrual period before starting a demanding exercise training programme (Clark, 2002:7). It is also suggested that the psychological stress related to heavy exercise training and competition is the cause for menstrual irregularities. Redman and Loucks (2005:750-751), however, found no differences in psychological tests or mood scores between amenorrhoeic and other athletes.

2.3.2 Exercise and body composition

Body composition and weight are two of the many factors that contribute to optimal exercise performance. Taken together, these two factors may affect an athlete's potential for success within a given sport. Body weight can influence an athlete's speed, endurance and power, whereas body composition can affect an athlete's strength, agility and appearance (Heyward & Wagner, 2004:710).

In many sports, body composition is important for optimal physical performance (Heyward & Wagner, 2004:710). In distance running for instance, a lean body appearance is emphasised as beneficial for performance (Greydanus & Patel, 2002:555). It is therefore not unusual for female athletes wanting to lose an extra 2,5 to 5 kg of weight although their weight is often normal or below normal by all medical standards (Manore, 2002:889). Depending on the sport, the impetus for this weight loss is the belief that a lower body weight will improve exercise performance. In addition, a smaller body size is easier to move through space and may reduce the risk of injury in high-impact sports (Manore, 2002:889-890).

Stokic et al. (2005:195) report that reduced body fat and weight loss are accompanied by later appearance of menstrual cycle disorders. It has been recognised that the critical amount of body fat leading to amenorrhoea is below 17%, while 22% is needed for regular menstrual cycles (Stokic et al, 2005:195; Warren, 2007:1393), and that secondary amenorrhoea can occur when the body fat falls below a critical threshold of 22% of bodyweight (Warren, 2007:1393). Athletes have lower values of body fat mass than sedentary individuals. Body fatness values for most female athletes range from 12 to 16%, depending on the sport (Stokic et al, 2005:195).

2.3.3 Exercise and disordered eating

In recent years, an increasing number of children and pre-adolescents have become concerned about their weight, leading to the development of eating disturbances (Halvarsson et al, 2002:284). Halvarsson et al. (2002:284) have observed a marked increase in dieting and the desire to be thinner among 9-14 year-old girls. Other researchers (Rolland et ah, 1997:274; De Oliveira et al, 2003:357) report that around 40% of girls between 8 and 13 years of age have actively tried to lose weight. De Oliveira

et al. (2003:357) found that the weight concerns and dissatisfaction of themselves

reported by girls in middle-childhood showed consistency over time. A meta-analysis of eating problems and athletic participation confirmed that athletes are more likely to experience disordered eating and that athletes participating at the elite level in so-called lean sports are particularly at risk (Smolak et al, 2000:371; De Oliveira et al, 2003:357).

Disordered eating seems to be common among female endurance athletes; where between 15 and 62% of female athletes were involved with bodyweight-control behaviours (De Oliveira et al, 2003:357). Disordered eating behaviours (anorexia/bulimia nervosa) can be unhealthy and expose the female athlete to serious health problems, performance impairment and injury (Burrows & Bird, 2000:23-25; De Oliveira et al, 2003:357). As the body initially adapts to the nutritional deficiencies, a decrease in performance may not be detected for some time, thus creating a misconception among athletes that disordered eating practices are harmless. However, food restriction and purging can result not only in menstrual dysfunction and potentially irreversible bone loss, but

psychological and medical complications as well, including depression, fluid/electrolyte imbalances and changes in endocrine/thermoregulatory systems (Burrows & Bird, 2000:23-25; De Oliveira et al, 2003:358). A variety of other factors, such as environment, mood and performance pressures, may contribute to the development of disordered eating patterns in the female athlete (Burrows & Bird, 2000:23-25; De Oliveira et al, 2003:357).

Compulsive exercise, defined as excessive exercise in addition to normal training regimens, is regarded as a form of "purging" or energy expenditure and is often overlooked in athletes (American Academy of Pediatrics, 2000:610; De Oliveira et al, 2003:357). One of the most common behaviours exhibited by sick athletes is inadequate energy intake (calories) for energy expended, resulting in an energy deficit (Papanek, 2003:595; Ronco, 2007:22). Occasionally, this is done unintentionally as training levels increase, but often this behaviour is used as a method to lose weight. Such patterns of disordered eating and compulsive exercise may impair athletic and work performance and can even increase the risk of injury (Putukian, 1998:677; West, 1998:65; De Oliveira

et al, 2003:358; Ronco, 2007:22). According to West (1998:65), athletes who decrease

their caloric intake, decrease their endurance, strength, reaction time, speed and their ability to concentrate. It can also result in menstrual dysfunction, irreversible bone loss and serious psychological and medical complications (Putukian, 1998:677; American Academy of Pediatrics, 2000:610). These complications can be potentially fatal as a death rate as high as 18% in non-athletes treated for disordered eating's has been reported (Beals et al, 1999:338; Sundgot-Borgen & Torstveit, 2003:48).

2.4 CONCLUSION

The female triad is a unique phenomenon that does not occur overnight but rather appears to gradually infiltrate the adolescent female athlete's lifestyle. Under pressure from parents, coaches, team-mates and themselves, many young women begin to fall into patterns of disordered eating and/or over-intense caloric expenditure without the support of adequate rest and nutrition. The triad is especially troubling due to the fact that, while each affliction can occur independently, each portion is often interrelated by a chain reaction. Amenorrhoea is likely to follow the caloric imbalance, which can lead to osteoporosis. This can result in termination of an athletic career as well as a chronically unhealthy adult life.

The potential factors accountable for menstrual irregularities in female athletes includes the intensity of exercise and low energy consumption, specific type and amount of training, early age initiation, previous menstrual dysfunction, low body mass index (BMI) or percentage body fat, pathological eating habits, and psychological stress.

It could be difficult to identify the female triad syndrome. When confronted by family, friends, coaches and physicians about their eating behaviour, athletes can be anywhere from elusive in their explanation to convinced that nothing is wrong. Although it is more common to find this syndrome affecting female athletes, it is certainly not exclusive to this population. In general, women struggle with the perception of the "perfect body image" society has unfairly placed upon them. Regardless of the circumstances, we as health-care providers, coaches and parents are ultimately responsible for protecting the wellness of the young women in our care. Therefore, we must provide a proper wellness environment by nurturing sound physical training and nutritional habits.

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